Provider Demographics
NPI:1568571560
Name:MARASCALCO, JOHN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:MARASCALCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHNNY
Other - Middle Name:A
Other - Last Name:MARASCALCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1300 SUNSET DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4086
Mailing Address - Country:US
Mailing Address - Phone:662-227-4463
Mailing Address - Fax:662-226-5257
Practice Address - Street 1:1300 SUNSET DR
Practice Address - Street 2:SUITE A
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4086
Practice Address - Country:US
Practice Address - Phone:662-227-4463
Practice Address - Fax:662-226-5257
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS03756207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS071800103Medicare PIN
MS070009293Medicare PIN